ML20203A148
| ML20203A148 | |
| Person / Time | |
|---|---|
| Site: | Comanche Peak  |
| Issue date: | 01/30/1986 |
| From: | Hansel J, Ross G EVALUATION RESEARCH CORP. |
| To: | |
| Shared Package | |
| ML20202J051 | List:
|
| References | |
| CPP-021, CPP-21, NUDOCS 8607170185 | |
| Download: ML20203A148 (11) | |
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EVALUATION RESEARCH CORPORATION COMANCHE PEAK RESPONSE TEAM PROJECT PROCEDURE FOR QA/QC ISSUE-SPECIFIC ACTION PLANS PROCEDURE NO: CPP-021 REVISION: 0 ISSUE DATE: 01/30/86 CPSES PROJECT CORRECTIVE ACTION i
Prepared by:
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/-f d Sg On-Site QA Representative Approved by:
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Review Team Leader
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j PDH 1553-15297-H1
CPP-021 R2visica: 0 1.0 PURPOSE This procedure establishes the method to determine the adequacy of action proposed by the Comanche Peak Steam Electric Station (CPSES)
Project to correct deviations and/or deficiencies reported by the QA/QC Review Team.
Moreover, this procedure establishes the methods to plan and document verifications of approved corrective actions to ensure their effective implementation as required.
2.0 APPLICABILITY This procedure is applicable to deviations determined to be safety-significant and programmatic deviations / deficiencies including QA/QC Program Deficiencies identified by the QA/QC Review Team in conjunction with Comanche Peak Response Team (CPRT) activities.
3.0 REFERENCES
3.1 CPP-010, " Preparation of Deviation Reports."
3.2 CPP-Oll, " Evaluations of Adverse Trend Analyses, Construction Deficiencies, and QA/QC Program Deficiencies."
3.3 CPP-016, " Safety-Significant Evaluations of Deviation Reports."
3.4 CPP-017, " Preparation of QA/QC Program Deficiency Reports."
3.5 CPP-020, "Out-of-Scope Observations."
3.6 CP-QP-16.3, " Processing CPRT Deviation Reports / Observation Notices."
3.7 CPP-004, " Project Working Files."
4.0 GENERAL The QA/QC Review Team transmits Deviation Reports (Construction Deviations); observations; QA/QC Program Deficiencies; analyses of adverse trends; and Safety-Signficant Evaluations (Construction Deficiencies) in accordance with established procedures.
(See References 3.1 through 3.5.)
Accordingly, Reference 3.6 addresses the method by which responsible CPSES Project personnel process the noted deviations and deficien-cies to ensure that acceptable actions to correct the unsatisfactory conditions are documented and effectively implemented.
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CPP-021 Revision: 0 To that end,' responsible QA/QC Review Team personnel and the Senior Review Team (SRT) of the CPRT review corrective action recommenda-tions submitted by the CPRT Project of: each deviation determined to be safety-signficant; each programmatic deviation or programmatic deficiency including QA/QC Program Deficiencies; and each deviation determined by the CPSES Project to meet the reportability criteria set forth in 10 CFR 50.55(e). Furthermore, the QA/QC Review Team verifies that the actions, as approved, are effectively accomplished.
4.1 Responsibilities 4.1.1 QA/QC Review Team Leader The RTL is responsible to determine the adequacy of corrective action proposals and obtain the (dis) approval of the SRT in those determinations.
In addition, the RTL reviews and approves Verification of Corrective Action Plans and Verifications of Corrective Action.
4.1.2 Senior Review Team, CPRT The SRT reviews determinations by the RTL relative to the adequacy of corrective action proposed by the CPSES Project. Moreover, the SRT is the final arbitrator should the RTL and the JPSES Project disagree in the adequacy of any corrective actions proposed by the CPSES Project.
4.1.3 QA/QC Issue Coordinators The responsible QA/QC Issue Coordinator reviews and, as required, approves Verification of Corrective Action Plans and Verifications of Corrective. Action.
4.1.4 QA/QC Interface Coordinator The QA/QC Interface Coordinator ensur?s that verifications of approved corrective action are conducted in a timely manner.
4.1.5 QA/QC Records Administrator The QA/QC Records Administrator distributes and controls memorandums, Verification of Corrective Action Plans, and Verifications of Corrective Action.
4.2 Policy Activities performed under this procedure shall conform to the policies contained in the latest CPRT Program Plan and the ERC Management Program Plan.
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CPP-021 R:visien: 0 Should an activity be designated the responsibility of the QA/QC Interface Coordinator or a QA/QC Issue Coordinator, or higher, it may be delegated by that individual to an individual under his or her supervision.
4.3 Conflicts In the case of a conflict between this procedure and the documents referenced in Section 4.2, the latter shall govert.,
4.4 Definitions None.
5.0 PROCEDURE 5.1 Review and Approval of Proposed Corrective Action The RTL ensures that the corrective action recommendations submitted by the CPSES Project are adequate based on the criteria specified in Attachment 6.1.
Accordingly, the RTL ensures that the results of corrective action reviews are documented on memorandums entitled "CPSES Project Corrective Action" addressed to the TUGC0 QA Coordinator. The memorandum specifically references the appropriate QA/QC observation / memorandum / report / analysis, indicates the signature (dis) approval of the RTL and the SRT, and includes, as an attachment, a copy of the corrective action submitted by the CPSES Project. Should the proposed corrective action be unacceptable, the memorandum also denotes the reasons (s) and the date, within 15 calendar days of the date of the memorandum, that resubmittal is required to ensure timely corrective action.
Resubmittals by the CPSES Project are reviewed and approved the same as the initial submittal.
NOTE: Should the CPSES Project maintain that the proposed corrective action is acceptable, the RTL refers the matter to the SRT for resolution.
Memorandums signed by the RTL are forwarded to the QA/QC Records Administrator for distribution and control in accordance with Paragraph 5.4.1.
5.2 Verification of Corrective Action Plans 5.2.1 Documentation The responsible QA/QC Issue Coordinator ensures the timely preparation of plans to verify the corrective action, as approved, on a form similar to Attachment
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6.2.
Plans should be established prior to the 1553-15297-111 4
CPP-021 Revision: 0 implementation of the approved corrective action and,
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as required, be specific relative to the scope of the verification process, the schedule for performing any verifications, any necessary material / services, and the appropriate accept / reject criteria. As a minimum, each plan shall be established prior to any verification of the approved corrective action.
j Any additional pages necessary shall be consecutively numbered and the total number of pages entered on the first page.
5.2.2 Review and Approval The responsible QA/QC Is. sue Coordinator and the RTL l
review each Verification of Corrective Action Plan to i
ensure that it is complete, accurate, comprehensive, j
and provides an acceptable method to verify the approved corrective action, then they sign and date the form.
N0iE:
Should the responsible QA/QC Issue j
Coordinator also be the preparer, he or
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she enters "N/A" in the appropriate
" APPROVED BY" block.
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4 Approved Verification of Corrective Action Plans are 3
forwarded to the QA/QC Records Administrator for retention in the file marked (later).
Each responsible QA/QC Issue Coordinator retains a copy of their plan (s) for reference during the verification process.
i 5.3 Verification of Corrective Action 5.3.1 Documentation
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The QA/QC Interface Coordinator maintains a matrix to ensure that verifications of acceptable corrective actions are conducted in a timely manner. The matrix denotes information necessary to ascertain whether the verification of corrective action was performed on the date scheduled; the name of the QA/QC Issue Coordinator responsible for performing the verification, whether 2
the corrective action was (un) satisfactorily implemented, etc.
l The responsible QA/QC Issue Coordinator ensures tnat verifications of acceptable corrective actions are documented by marking the RTL's/SRT's memorandum l
maintained by the QA/QC Records Adminstrator "C/A VERIFIED (UN) SATISFACTORY. REFER TO ATTACHMENT," then indicates his or her name, and the date the l
verification was performed.
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i CPP-021 Rzvisien: 0 The attachment (similar to Attachment 6.3) provides t
information relative to the verification. That is, whether the implementation of the corrective action was completely satisfactory; performed in a timely manner; i
any unacceptable conditions, etc.
5.3.2 Review and Approval The responsible QA/QC Issue Coordinator and the RTL review Verifications of Corrective Action to ensure j
that they provide clear, complete, and objective evidence relative to the reported disposition, then they sign and date the form.
NOTE: Should the responsible QA/QC Issue Coordinator also be'the preparer, he or she enters "N/A" in the appropriate
" APPROVED BY" block.
The RTL refers reports of unsatisfactory corrective action implementation to the SRT for resolution.
Reports of satisfactory corrective action implementa-tion are forwarded to the QA/QC Records Adminstrator foc distribution and control in accordance with Paragraph 5.4.2.
5.4 Distribution and Control The QA/QC Records Administrator maintains records associated with CPSES Project corrective action in the file marked (later). Records associated with corrective action proposed by the CPSES Project, e.g., the RTL's memorandum, or verifications planned, are segregated from records associated with corrective action verified by the QA/QC Review Team to be satisfactory, e.g., the RTL's memorandum marked "C/A VERIFIED SATISFACTORY.."
with the Verification of Corrective Action attached.
5.4.1 RTL's Memorandums the QA/QC Records Administrator distributes the RTL's memorandums endorsed by the SRT which accept / reject corrective action proposed by the CPSES Project on uniquely numbered transmittals which include provision for the TUGC0 QA Coordinator to acknowledge receipt.
In addition, the QA/QC Records Administrator maintains records to ensure that the TUGC0 QA Coordinator is in receipt of all applicable memorandums, e.g., a file of transmittals forwarded to and received from the TUGC0 QA Coordinator in a loose-leaf binder. Copies are distributed to the 1553-15297-H1 6
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CPP-021 f.
R2 vision: 0
- CPRT Program Director, Responsible QA/QC Issue Coordinator, and the t
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- QA/QC Interface Coordinator.
i Copies sent to the QA/QC Interface Coordinator ensure I
verification of corrective action in a timely manner, i
f 5.4.2 Verifications of Corrective Action i
l The QA/QC Records Administrator distributes approved Verifications of Corrective Action to the TUGC0 QA Coordinator. Copies are distributed to the CPRT Program Director and the QA/QC Interface Coordinator.
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5.4.3 Records Turnover Upon the satisfactory completion of each verification, the QA/QC Records Administrator assembles the appro-i priate RTL's memorandum, the approved Verification of Corrective Action Plan, the approved verification of I
corrective action, and any pertinent data for trans-mittal to the CPRT Central File in accordance with i
Reference 3.7.
i 6.0 ATTACKMENTS i
6.1 Corrective Action Requirements / Criteria.
6.2 Verification of Corrective Action Plan (Sample).
f 6.3 Verification of Corrective Action (Sample).
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Attachm:nt 6.1 CPP-021 Rzvision:
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CORRECTIVE ACTION REQUIREMENTS / CRITERIA In general, the response should address the deficiency requiring i
corrective action.
l CAUSE I
Ensure that the feature (s) of the existing control (s) that permitted the i
observed condition (s) to occur is described.
Instructions, procedures, etc., comprise the controls; activities, as performed, constitute
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implementation. Typically, the causative feature will be one, or a combination, of the following:
a.
Established controls lack provisions to prevent the observed condition or to check for it.
Ensure that the specific lack is identified.
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b.
Established controls contain ambiguous, conflicting, or inappropriate requirements thus increasing the likelihood of I
the observed condition to occur. Ensure that the ambiguity, l
conflict, and/or inappropriate requirements is identified.
J c.
Failure to follow one of more of the requirements of the i
established controls due to specific reasons.
Ensure that the i
requirements which were not followed and the reason why arE identified.
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EXTENT OF CONDITION i
Ensure that the extent of the same or similar conditions within the population / area / item from which the sample was drawn is identified and how the extent was determined. The extent of the condition must usually be determined by survey or investigation.
In some cases, the extent may be inferred or deduced based on the nature of the reinspection / review or i
the condition.
l ACTION TO CORRECT EXISTING CONDITION I
J Ensure that the actions necessary to correct both the reported conditions and the same or similar conditions that were found to exist when the j
extent of the condition was determined is identified.
Any decision not j
to correct all existing conditions of the reported type shall be Justified in terms of lack of effect on quality. The measures to be l
taken to correct possible degradation of quality in design work completed due to the type of condition reported shall also be addressed.
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Attachmznt 6.1 CPP-021 Revision: c
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ACTION TO PREVENT RECURRENCE Ensure that the action necessary to prevent the reported or similar conditions from recurring is described, e.g., the programmatic actions to be taken, such as procedure changes, institution of specific training, modification of special processes, etc.
Such actions are expected to I
eliminate the cause(s) identified.
It is unacceptable to caution individuals to be "more careful" or to " comply with requirements".
It is acceptable to revise existing procedures / instructions so that they better match the controls that are acturall being practiced, provided such controls have been determined to be adequate under governing require-ments.
It is unacceptable to change such procedures / instructions merely to relax requirements unless existing procedures / instructions can be clearly shown to exceed regulatory requirements.
COMPLETION DATES When extenuating circumstances prevent completion of the action within 60 calendar days, the schedule to ccmplete the actions to correct and i
prevent the reported and any similar conditions shall be provided.
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,.2 CPP-021 Ravision: 0 Page 1 of 1 VERIFICATION OF CORRECTIVE ACTION PLAN l
i CnNANellE rFah kES11ME TEMI VEHtFICATION OF CUNEECTIVE ACTION Pl.AN PACE I Of I
INSTRUCTIONS:
DOCUMENT Tile PLAN IOR VLatFYlNG Tile ACTION TO CORRECT Tile UN9ATISFACTORY CONDITION (S) DESCRIBED IN Tite REPORTED DEVIATION (S) REFERENCED BELOW.
REFERENCES (INCL.l!OE THE NINBF.R AND DESCRIPTinN):
PLAN (ATTAcil ADI)lifoNAl. PACES AS REQUIRED):
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e PREPARED BY DATE:
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i APFRO\\T.D BY DATE:
hk/QCiSSLECOORDINATOR APFROVED BY:
DATEt QA/yC REVIEW 1EAM LEADt.H l
t CPP 021.1, Revision 0 l
1553 15297 111 i
1 1553-15297-H1 a
Attachm:nt 6.3 CPP-021 Revision: 0 Page 1 of I hi VERIFICATION OF CORRECTIVE ACTION COMANCilE PFAK RESPONSE TEAM VERIf! CATION OF CUHHECTIVE ACTION PAGE 1 0F INSTRUCTIONS:
VERIFY BY REINSFECTION/RFVif,W THAT Tile CORRFCTIVE ACTION APPROVED BY TIIE QA/QC REVIEW TEAM LEADER /SFNIOR REVIEW TEAM CONCERNING THE REPriRIFD l>EVIATION{S) ktttNEhCLD liLLOW llAS IllAVE) BEFN COMPLETED AND SATISFACTORILY INPLEr1ENTFD.
VERIFIED CONDITION (Which supports the results indicated below):
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i RESULTS:
l TIIE VERIFIED CONDITION DOES/DOFS Not COMPLF.TELY AND SATISFACTORILY l
IMPLEttENT THE CORRECTIVE ACTION AS REQUIRED.
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PREPARED BY:
DATEt APPROVED BYr DATE:
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05/iglSM;E CuokulNAION APPROVED BY:
DATL yA/yC HEVliW IEAtt LF.ADER CPP-021.2, Revision 0 1553*IS297 HI
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